Name (please print or type) ________________________________________________________________  
          
      
Affiliation (for name badge) _______________________________________________________________
      
      
Email: _______________________________________________
      
      
Check one: (fee includes lunch)

___ ASIS Member:  $65.00

___ Non-member:  $75.00

___ Student/Retiree/Between jobs:  $20.00


Check Lunch Preference:

(Choices include whole fruits, freshly baked cookie, chocolate mint candy, beverage.)

___  Beef & Cheddar.  Roasted medium rare with cheddar cheese, mango chutney and red 
     onions on a whole grain roll.

___  Roasted Turkey Breast.  Served with cranberry chutney on whole wheat bread.

___  Asian Noodle Salad.  Lo Mein noodles tossed with fresh green vegetables and rice
     wine vinaigrette.


 
      
Make out check to: "NEASIS"   


Or, charge my credit card: ___ MasterCard     ___ Visa     ___ American Express

Number ___________________________________________  Expiration date: __________________

Signature  ____________________________________________________________________________

Registrations MUST be received by December 1.
No confirmations will be sent. Receipts will be available at the door, upon request.        

Please print this form and mail to:

NEASIS Registration, MIT, Room 7-238, 77 Massachusetts Avenue Cambridge, MA 02139

 

(please copy form for additional registrations)